Assessing the Efficiency of Countries in Making Progress Towards Universal Health Coverage: A Data Envelopment Analysis of 172 Countries

Background: Maximising efficiency of resources is critical to progressing towards Universal Health Coverage (UHC) and therefore the Sustainable Development Goal (SDG) for Health. This study estimates the technical efficiency of national health spending in achieving UHC and its determinants. Methods: A two-stage efficiency analysis using Simar and Wilson’s double bootstrap data envelopment analysis investigates how efficiently countries convert health spending into UHC outputs (measured by service coverage and financial risk protection) for 172 countries. We use World Bank and World Health Organization data from 2015. Thereafter, the environmental factors affecting efficient progress toward UHC goals are identified. Findings: The mean bias-corrected technical efficiency score across 172 countries is 85·7% (68·9% for low income and 95·5% for high income countries). High-achieving middle- and low-income countries such as El Salvador, Colombia, Rwanda and Malawi demonstrate that peer-relative efficiency can be attained at all incomes. Governance capacity, income and education are significant determinants of the efficiency score. Sensitivity analysis suggests that results are robust to changes. Interpretation: We provide a 2015 baseline for cross-country UHC technical efficiency scores. If countries wish to improve their UHC outputs within existing budgets, they should identify their current efficiency and try to emulate more efficient peers. Policy-makers should focus on strengthening institutions, improving data availability on UHC indicators and implementing known best practices to replicate efficient systems. Using resources more efficiently is likely to positively impact UHC coverage goals and health outcomes, and without addressing gaps in efficiency progress towards achieving the SDGs will be impeded. Funding Statement: None. Declaration of Interests: We declare no competing interests.